Critical Incident Report User Guide Form 470-4698 - Iowa Medicaid ...

Iowa Department of Human ServicesIMPA Incident Reporting FormIMPA Users Guide – Revised May, 2010MEMBER’S INTERPERSONAL RELATIONSHIPS WITHIN THEIR ENVIRONMENT EVALUATED, ANDACCOMODATED / MODIFIED, IF NECESSARY, FOR SAFETY REASONS: The member’s safety and welfare are assured within their family or social network.OTHER: - Select and describe the specific environmental review in the narrative box.RESOLUTION FOLLOWING MEMBER REVIEW: - Select this checkbox if any previous fields in this section weremarked. Describe specifically how the actions selected will prevent or diminish the probability of futureoccurrences.NO RESOLUTION REQUIRED: - If no previous fields were selected then select this checkbox. Describe in thenarrative box how this adverse incident was isolated with a minimal probability of reoccurrence.PART 4 – SYSTEM MODIFICATIONSPart 4 is optional. Up to this point, the provider has completeddiscovery activities and resolved incident-specific situations. Byanalyzing trend data on incidents the provider may implementsystem changes as a proactive measure. If this occurs, this part ofthe incident reporting system will capture information on systemresolutions.ModificationsCommentsThe second section of Part 4 is an opportunity for the provider toadd additional comments. Please select all that apply.Figure 36: System Resolutions, Part 4 System ModificationsPart 4: SystemImprovementsFields under Systemic Resolution include:POLICY: - Reviewed formal written policy orprocedure governing the activity, and modify asneeded. Staff are able to reference agencyguidelines or protocols.CONSISTENT IMPLEMENTATION OF POLICY: –Reviewed, and modified as necessary, to assurethat verbal instructions are the same asprocedural requirements. Policies andprocedures are up to date.ADEQUATE POLICY: - Policies and procedures arecomplete, meet regulatory requirements, andare consistent with established standards andaccepted practice expectations. Policies andprocedures are clear and concise.COMMUNICATION AND AWARENESS: - There is adequate communication re: new policy requirements. Staff andothers are aware of changes or revisions to policy or procedure.Page 30